Transcript Medicare, CPT, RVU: Update, Problems, & Directions

The New Health & Behavior
Assessment Codes:
The Coding Perspective
American Psychological Association
08.25.02; Chicago
Antonio E. Puente, Ph.D.
Department of Psychology
University of North Carolina at Wilmington
Wilmington, NC 28403
CPT: Background

American Medical Association
– Developed by Surgeons (& Physicians) in 1966 for
Billing Purposes
– 7,500 Discrete Codes
– American Psychological Association as HCPAC
member

HCFA/CMS
– AMA Under License with CMS
– CMS Now Provides Active Input into CPT
CPT: Background/Direction

Current System = CPT 5
 Categories
– I= Standard Coding for Professional Services
– II = Performance Measurement
– III = Emerging Technology
CPT: Applicable Codes

Total Possible Codes = 7,500
 Possible Codes for Psychology =
Approximately 40 to 60
 Sections = Five Separate Sections
– Psychiatry
– Biofeedback
– Central Nervous Assessment
– Physical Medicine & Rehabilitation
– Health & Behavior Assessment & Management
CPT: Health & Behavior
Assessment & Mngmt.

Purpose: Medical Diagnosis
 Time: 15 Minute Increments
 Assessment
 Intervention
Rationale: General

Acute or chronic (health) illness may not
meet the criteria for a psychiatric diagnosis
 Avoids inappropriate labeling of a patient as
having a mental health disorder
 Increases the accuracy of correct coding of
professional services
 May expand the type of assessments and
interventions afforded to individuals with
health problems
Rationale: Specific Examples

Patient Adherence to Medical Treatment
 Symptom Management & Expression
 Health-promoting Behaviors
 Health-related Risk-taking Behaviors
 Overall Adjustment to Medical Illness
Overview of Codes

New Subsection
 Six New Codes
– Assessment
– Intervention

Established Medical Illness or Diagnosis
 Focus on Biopsychosocial Factors
Assessment Explanation

Identification of psychological, behavioral,
emotional, cognitive, and social factors
 In the prevention, treatment, and/or
management of physical health problems
 Focus on biopsychosocial factors (not
mental health)
Assessment (continued)

May include (examples);
– health-focused clinical interview
– behavioral observations
– psychophysiological monitoring
– health-oriented questionnaires
– and, assessment/interpretation of the
aforementioned
Intervention Explanation

Modification of psychological, behavioral,
emotional, cognitive, and/or social factors
 Affecting physiological functioning, disease
status, health, and/or well being
 Focus = improvement of health with
cognitive, behavioral, social, and/or
psychophysiological procedures
Intervention (continued)

May include the following procedures
(examples);
– Cognitive
– Behavioral
– Social
– Psychophysiological
Diagnosis Match

Associated with acute or chronic illness
 Prevention of a physical illness or disability
 Not meeting criteria for a psychiatric
diagnosis or representing a preventative
medicine service
Related Psychiatric Codes

If psychiatric services are required (9080190899) along with these, report
predominant service
 Do not report psychiatric and these codes on
the same day
Related Evaluation &
Management Codes

Do not report Evaluation & Management
codes the same day
Code X Personnel (examples)

Physicians (pediatricians, family physicians,
internists, & psychiatrists)
 Psychologists
 Advanced Practice Nurses
 Clinical Social Workers
 Other health care professionals within their
scope of practice who have specialty or
subspecialty training in health and behavior
assessments and interventions

96150
Health & Behavior
Assessment Codes
– Health and behavior assessment (e.g., health-focused
clinical interview, behavioral observations,
psychophysiological monitoring, health-oriented
questionnaires)
– each 15 minutes
– face-to-face with the patient
– initial assessment

96151
– re-assessment
Health & Behavior Intervention
Codes

96152
– Health and behavior intervention
– each 15 minutes
– face-to-face
– individual

96153
– group (2 or more patients)

96154
– family (with the patient present)

96155
– family (without the patient present)
Relative Values for Health &
Behavior A/I Codes

96150
 96151
 96152
 96153
 96154
 96155
=
=
=
=
=
=
.50
.48
. 46
.10
.45
.44
Sample of Commonly Asked
Questions

When Are These Codes to be Used for
Psychotherapy Codes?
– Depends on the disorder
– DSM = psychotherapy
– ICD = health and behavior
Samples Questions
(continued)

Do These Codes Include
Neuropsychological Testing?
– No
– Formal testing should be coded between 96100
and 96117, depending on the situation
Sample Questions (continued)

Who Can Perform These Services?
– Physicians can perform these services
– Application of these codes will vary according
to licensure/credentialing requirements of the
state, area, providence and/or institution
– Payment may also vary
96150 Clinical Example

A 5-year-old boy undergoing treatment for acute
lymphoblastic leukemia is referred for assessment
of pain, severe behavioral distress and
combativeness associated with repeated lumbar
punctures and intrathecal chemotherapy
administration. Previously unsuccessful
approaches had included pharmacologic treatment
of anxiety (ativan), conscious sedation using
Versed and finally, chlorohydrate, which only
exacerbated the child’s distress as a result of
partial sedation. General anesthesia was ruled out
because the child’s asthma increased anesthesia
respiratory risk to unacceptable levels.
96150 Description of
Procedure


The patient was assessed using standardized tests and
questionnaires (e.g., the Information-seeking scale,
Pediatric Pain Questionnaire, Coping Strategies Inventory)
which, in view of the child’s age, were administered in a
structured format. The medical staff and child’s parents
were also interviewed. On the day of a scheduled medical
procedure, the child completed a self-report distress
questionnaire.Behavioral observations were also made
during the procedure using the CAMPIS-R, a structured
observation scale that quantifies child, parent, and medical
staff behavior.
An assessment of the patient’s condition was performed
through the administration of various health and behavior
instruments.
96151 Clinical Example

A 35-year-old female, diagnosed with chronic asthma,
hypertension and panic attacks was originally seen ten
months ago for assessment and follow-up treatment.
Original assessment included extensive interview
regarding patient’s emotional, social, and medical history,
including her ability to manage problems related to the
chronic asthma, hospitalizations, and treatments. Test
results from original assessment provided information for
treatment planning which included health and behavior
interventions using a combination of behavioral cognitive
therapy, relaxation response training and visualization.
After four months of treatment interventions, the patient’s
hypertension and anxiety were significantly reduced and
thus the patient was discharged. Now six months
following discharge, the patient has injured her knee and
has undergone arthroscopic surgery with follow-up therapy


96151 Description of
Procedure
Patient was seen to reassess and evaluate
psychophysiological responses to these new health
stressors. A review of the records from the initial
assessment, including testing and treatment intervention, as
well as current medical records was made. Patient’s
affective and physiological status, compliance disposition,
and perceptions of efficacy of relaxation and visualization
practices utilized during previous treatment intervention
are examined. Administration of anxiety
inventory/questionnaire (e.g., Burns Anxiety Inventory) is
used to quantify patient’s current level of response to
present health stressors and compared to original
assessment levels. Need for further treatment is evaluated.
A reassessment of the patients condition was performed
through the use of interview and behavioral health
instruments.
96152 Clinical Example

A 55-year-old executive has a history of cardiac arrest,
high blood pressure and cholesterol, and a family history
of cardiac problems. He is 30 lbs. overweight, travels
extensively for work, and reports to be a moderate social
drinker. He currently smokes one-half pack of cigarettes a
day, although he had periodically attempted to quit
smoking for up to five weeks at a time. The patient is
considered by his physician to be a “Type A” personality
and at high risk for cardiac complications. He experiences
angina pains one or two times per month. The patient is
seen by a behavior medicine specialist. Results from the
health and behavior assessment are used to develop a
treatment plan, taking into account the patient’s coping
skills and lifestyle.
96152 Description of
Procedure

Weekly intervention sessions focus on
psychoeducational factors impacting his
awareness and knowledge about his disease
process, and the use of relaxation and
guided imagery techniques that directly
impact his blood pressure and heart rate.
Cognitive and behavioral approaches for
cessation of smoking and initiation of an
appropriate physician-prescribed diet and
exercise regimen are also employed.
96153 Clinical Example

A 45-year-old female is referred for smoking
cessation secondary to chronic bronchitis, with a
strong family history of emphysema. She smokes
two packs per day. The health and behavior
assessment reveals that the patient uses smoking
as a primary way of coping with stress. Social
Influences contributing to her continued smoking
include several friends and family members who
also smoke. The patient has made multiple
previous attempts to quit “on her own”. When
treatment options are reviewed, she is receptive to
the recommendation of an eight-session group
cessation program.
96153 Description of
Procedure

The program components include
educational information (e.g., health risks,
nicotine addiction), cognitive-behavioral
treatment (e.g., self-monitoring, relaxation
training, and behavioral substitution), and
social support (e.g., group discussion, social
skills training). Participants taper intake
over four weeks to a quit date and then
attend three more sessions for relapse
prevention. Each group sessions lasts 1.5
hrs.
96154 Clinical Example

Tara is a 9-year-old girl, diagnosed with insulin dependent diabetes
two years ago. Her mother reports great difficulty with morning and
evening insulin injections and blood glucose testing. Tara whines and
cries, delaying the procedures for 30 minutes or more. She refused to
give her own injections or conduct her own blood glucose tests,
claiming they “hurt”. Her mother spends many minutes pleading for
her cooperation. Tara’s father refuses to participate, saying he is
“afraid” of her needles. Both parents have not been able to go to a
movie or dinner alone, because they know of no one who can care for
Tara. Tara’s ten year old sister claims she never has any time with her
mother, since her mother is always occupied with Tara’s illness. Tara
and her sister have a very poor relationship and are always quarreling.
Tara’s parents frequently argue; her mother complains that she gets no
help from her husband. Tara’s father complains that his wife has no
time for anyone except Tara.
96154 Description of
Procedure

A family-based approach is used to address the multiple components of
Tara’s problem behaviors. Relaxation and exposure techniques are
used to address Tara’s father’s fear of injections, which he has
inadvertently has been modeling for Tara. Tara is taught relaxation and
distraction techniques to reduce the tension she experiences with finger
sticks and injections. Both parents are taught to shape Tara’s behavior,
praising and rewarding successful diabetes management behaviors, and
ignoring delay tactics. Her parents are also taught judicious use of
time-out and response cost procedures. Family roles and
responsibilities are clarified. Clear communication, conflictresolution, and problem-solving skills are taught. Family members
practice applying these skills to a variety of problems so that they will
know how to successfully address new problems that may arise in the
future.
96155 Clinical Example

Greg is a 42-year-old male diagnosed with cancer
of the pancreas. He is currently undergoing both
aggressive chemotherapy and radiation treatments.
However, his prognosis is guarded. At present, he
is not in the endstage disease process and therefore
does not qualify for Hospice care. The patient is
seen initially to address issues of pain
management via imagery, breathing exercises, and
other therapeutic interventions to assess quality of
life issues, treatment options, and death and dying
issues.
96155 Description of
Procedure

Due to the medical protocol and the patient’s inability to
travel to additional sessions between hospitalizations, a
plan is developed for extending treatment at home via the
patient’s wife, who is his primary home caregiver. The
patient’s wife is seen by the healthcare provider to train the
wife in how to assist the patient in objectively monitoring
his pain and in applying exercises learned via his treatment
sessions to manage pain. Issues of the patient’s quality of
life, as well as death and dying concerns, are also
addressed with assistance given to the wife as to how to
make appropriate home interventions between sessions.
Effective communication techniques with her husband’s
physician and other members of his treatment team
regarding his treatment protocols are facilitated.
CPT: Model System

Psychiatric
 Neurological
 Non-Neurological Medical
CPT: Non-Neurological
Medical Model
(Children & Adult)

Interview & Assessment
– 96150 (initial)
– 96151 (re-evaluation)

Intervention
– 96152 (individual)
– 96153 (group)
– 96154 (family with patient)
– 96155 (family without patient)
CPT: New Paradigms

Initial Psychiatric
 Next Neurological
 Now Medical
 Medical as Evaluation & Management
CPT: Evaluation &
Management

Role of Evaluation & Management Codes
– Procedures
– Case Management
Limitations Imposed by AMA’s House of
Delegates
 Health & Behavior Codes as an Alternative
to E & M Codes

Questions? Answers…

Questions?

Contact:
– clinicalneuropsychology.us
– [email protected]
– 910.962.7010